Acute Stroke

Acute ischemic stroke is sudden onset of focal neurological deficit that occurs from occlusion or ischemia in the territory supplied by cerebral artery.
What are the symptoms?
Slurring of speech, motor weakness and facial paralysis.
Why to treat?
Recanalisation has been shown to be the most important modifiable prognostic factor for favorable outcome in ischemic stroke treatment.
Successful recanalisation overall increases the chance of favourable outcome 4-fold compared to patients without recanalisation, and decreases the mortality rate 4-fold.
The importance of recanalisation is even more pronounced in basilar artery occlusion, where the chance of an independent life is only 2 % in patients without recanalization.

Thrombectomy/ Thrombolysis
From groin access, the occluded intracranial artery is reached by catheters very fast, in hands of our experienced team, as quickly as possible, and a stent is deployed with suction and retrieval of clot by mechanical methods thus, achieving rapid and efficient brain perfusion and preventing brain damage.
This procedure is a usually a short rapid procedure with high success rate correlating with duration of onset of patient symptoms. Now patients can be treated upto 24-48 hours of onset, however, the earlier, the better/
Furthermore, possible reduction or waiver of thrombolytic drugs may lower the risk of SICH. Sometimes, clot dissolution may be done by directly infusing clot-buster drugs through the catheters with advantage of direct clot dissolution at face of the clot.

Intracranial Aneurysm

An aneurysm is a balloon-like swelling that results from a weakness in the wall of blood vessels supplying blood to the brain.
What are the symptoms?
Headache (worst headache of life)
Vomiting
Seizure
Focal deficit
Unconsciousness
Why to treat?
There is a risk that the aneurysm will rupture (burst suddenly) and cause a brain hemorrhage (bleed).
The risk of repeated bleeding is 35% within the first 14 days after the first bleed. So timing of treatment is important - usually within 72 hours of the first bleed.

Coiling involves approaching the aneurysm from inside the blood vessel, avoiding the need to open the skull.
Small metallic coils (mainly composed of Platinum) are inserted into the aneurysm through the arteries that run from the groin to the brain. The coils remain inside the aneurysm: they are not removed and seal the swelling completely so that they do not bleed again.
Blood then clots around the coils sealing off the weakened area with preservation of blood flow to the normal brain.
Real time fluoroscopy (Xray) images enable the endovascular team to assess the normal arteries continuously to prevent any complications arising from the procedure, thus, further reducing complication rates when compared to conventional open surgery.

Arteriovenous Malformation (AVM)

AVMs are abnormal bunch of vessels which form from abnormal communication between vessels supplying (arteries) and taking away blood (veins) leading to flow disturbance in tissues.
What are the symptoms?
Headache (worst headache of life)
Vomiting
Seizure
Focal deficit
Unconsciousness
Why to treat?
Bleeding may injure the surrounding brain resulting in a stroke, with possible permanent disability or even death. The risk of bleeding is 4% per year, which means that 4 out of every 100 people with an AVM will have a bleed (hemorrhage) during any one year.

Embolization treatment of AVM is also known as Embolotherapy or Endovascular therapy. It can be curative (with total cure in single or multiple sessions), palliative (to improve symptoms), Pre-operative or pre-radiosurgery, or targeted (to deal high flow component or rupture point)
Embolization has been used to treat AVM since the early 1980’s. This procedure involves the injection of glue or other non-reactive liquid adhesive material into the AVM in order to block it off. For this purpose, a small catheter is passed through a groin vessel all the way up into the blood vessels supplying the AVM.
The glue rapidly hardens as it is injected into the AVM. The result is that the flow of blood through the AVM is blocked off. When there is no longer any blood passing through an AVM, there is no further risk of bleeding. For the larger size AVM embolization is often done in stages so that each time a portion of the AVM is blocked off.

Tumor Embolization

Tumors that are hypervascular have dominant arterial supply. Closing the arteries supplying the tumor and reduction of tumor blush is the ultimate risk management strategy to reduce operative blood loss.
Tumor embolization by shutting off the abnormal arterial supply of the tumor can be a palliative measure too, if surgery is not possible. Shrinkage of tumor size is an additional benefit of tumor embolization.
How is the tumor diagnosed?
CT/MR of the brain/spine with typical site and morphology of a tumor leads to a diagnosis.

Tumor embolization is a procedure that can be performed preoperative/palliative to a planned surgical resection. Embolization shuts down the blood supply to a tumor reducing blood loss during surgical resection. A secondary benefit from embolization can be that tumor margins are more easily identified and a tumor can be removed more completely and with less effort. Tumors of the spine, head, and neck that can be embolized have relatively large blood vessels supplying the tumor.
Some tumors can be accessed percutaneously using fine needles and directly embolized using embolic materials.
Which tumors can be endovascularly/percutaneously embolized?
Tumors that show an abnormal blush or are hypervascular (feeding arteries can be identified) can be endovascularly managed. Commonly embolized tumors are hemangioblastoma, meningiomas, JNA (Juvenile nasopharyngeal angiofibromas), ABC (Aneurysmal bone cysts), Paragangliomas (Carotid body tumors, glomus jugulare, glomus vagale), hemangiopericytoma, vascular metastasis (renal cell cancer, thyroid cancer, choriocarcinoma, etc).

Carotid Artery Stenting (CAS) and Vertebral Artery Stenting

What is carotid stenosis and why does it happen?
Like the blood vessels of the heart (coronary arteries), the carotid arteries also develop atherosclerosis (usually age related), the build-up of fat and cholesterol deposits, called plaque, on the inside of the arteries. Over time, the build-up narrows the artery (carotid artery stenosis), decreases blood flow to the brain and can lead to a stroke. Carotid artery stenosis can present with no symptoms or with symptoms such as transient ischemic attacks (TIAs) or strokes.
What is carotid artery stenting (CAS)?
Carotid artery stenting (CAS) is an endovascular surgical procedure where a stent is deployed within the lumen of the carotid artery after balloon angioplasty (dilatation) to open up the stenosed lumen of the vessel and thereby prevent strokes in future.

Carotid stenting is a day care procedure without need of general anesthesia. Patient is conscious at time of the procedure. CAS is also the preferred therapy for patients who are at an increased risk with carotid surgery. High risk factors include medical comorbidities (severe heart disease, heart failure, severe lung disease, age > 75/80, etc.) and anatomic features (contralateral carotid occlusion, radiation therapy to the neck, prior ipsilateral carotid artery surgery, intra-thoracic or intracranial carotid disease) that make surgery difficult or risky.

Cerebral DSA/ “Angiography”

Cerebral Angiography can help diagnose and plan treatment for -

• an aneurysm (a rupture in the wall of an artery)
• arteriosclerosis (narrowing of the arteries)
• an arteriovenous malformation (a mass of dilated interconnected blood vessels)
• vasculitis (blood vessel inflammation)
• tumors
• blood clots
• tears in the lining of an artery

• severe headaches
• loss of memory
• slurred speech
• dizziness
• blurred or double vision
• weakness or numbness
• loss of balance or coordination

Cerebral angiography is a diagnostic test that can help evaluate the intracranial and neck cerebral and venous vasculature.
The procedure uses a catheter—a long, flexible tube—and an external X-ray to get very detailed images of these vessels. Using the catheter, a contrast dye is injected into your carotid artery. The carotid artery is the blood vessel in your neck that carries blood to your brain.
Cerebral angiography is also called “intra-arterial digital subtraction angiography.”

Spinal AVM Diagnosis and Embolization

What is spinal AVM?
Spinal Cord AVM (arteriovenous malformation) is an abnormal connection between arteries and veins on or inside the spinal cord. AVM usually occurs in older children and younger adults (less than 50 years).
What are the symptoms of spinal AVM?
An AVM causes abnormal blood flow within the spinal cord and this can result in a number of problems, including haemorrhage (internal bleeding) and/or a stroke in the spinal cord. This can in turn result in a sudden or gradual loss of movement of limbs, such as temporary or permanent paralysis, abnormal sensations such as tingling, “pins and needles”, or a complete loss of feeling in the limbs. There may also be a loss of urinary bladder or bowel control. If untreated, AVM can progress to a severe disability and although rare, can result in death.
How is spinal AVM diagnosed?
CT or MRI cross sectional imaging can lead one to suspect a spinal AVM, however, diagnosis is only confirmed on DSA (catheter based angiography). DSA helps in understanding the angioarchitecture of the AVM and also guide further management.

Endovascular procedure for spinal AVM is done for the diagnosis and management of the AVM. Fine catheters are used to access the small intercostal branches arising from aorta. Through them, the artery feeding the spinal AVM is accessed and embolic material is injected.
Endovascular embolization atleast halts the progression of the disease. You can expect a complete recovery from embolization of spinal AVM, however, the chances of recovery depend on the time of diagnosis and treatment.

Intracranial Stenting

What is ICAD?
Intr\acranial stenosis /ICAD (Intracranial Atherosclertic Disease) is a narrowing of an artery inside the brain that can lead to stroke. Stenosis is caused by a buildup of plaque inside the artery wall that reduces blood flow to the brain. Atherosclerosis that is severe enough to cause symptoms carries a high risk of stroke and can lead to brain damage and death.
Symtoms are same as that for acute stroke.
Treatments aim to reduce the risk of stroke by controlling or removing plaque buildup and by preventing blood clots.
What treatments are available?
The goal of treatment is to reduce the risk of stroke. Treatment options for intracranial stenosis vary according to the severity of the narrowing and whether you are experiencing stroke-like symptoms or not. Patients are first treated with medication and are encouraged to make lifestyle changes to reduce their risk of stroke. Intracranial stenosis can be treated with medications that minimize risk factors, including high cholesterol and blood pressure. If you smoke, you may be prescribed medications that help you quit. Patients with diabetes will be advised to maintain tight control of their blood sugar through a healthful diet and careful monitoring.
Endovascular treatment is done for those, in patients whose symptoms do not resolve without medical management.

Endovascular treatments (Balloon angioplasty / stenting) is a minimally invasive endovascular procedure that include balloon angioplasty of the stenotic artery, with or without placement of an endoluminal stent. Options of placing a Drug Eluting Stent or using a Drug eluting Balloon which may deposit an antithrombotic drug at the plaque site and may not require the need of placing a stent.
The aim is to reduce stenosis by less than 50%, as a small increase of the vessel diameter results in large increases in blood flow to the brain. The balloon is then deflated and removed. In some cases, a self-expanding mesh-like tube called a stent is placed over the plaque, holding open the artery.
Angioplasty is typically recommended for patients who have high-grade artery stenosis (greater than 70%) and recurrent TIA or stroke symptoms despite best medication treatment. Angioplasty / stenting can successful reduce the stenosis to less than 30% without complications in 60 to 80% of patients.

Venous Thrombolysis and Venous Stenting Procedures

Cerebral venous sinus thrombosis (CVST) is an increasingly diagnosed disease with a wide range of symptoms, ranging from a mild headache to cerebral herniation. A potentially devastating syndrome, CVST has been associated with a mortality rate of 6-10%. In prospective studies, the overall rate of death and dependency from CVST ranges from 8.8 to 44.4%. Systemic anticoagulation remains the first-line treatment. However, a percentage of patients deteriorate despite medical therapy. These cases have resulted in the development of thrombolysis or endovascular treatment for CVST. The use of endovascular treatment of CVST have been promising.
Venous outflow obstruction is a recognised contributing factor in some of the patients with Idiopathic Intracranial Hypertension/recurrent tinnitus. Proper angiogram and pressure gradients (pressure waveforms) are recorded during an angiogram and thereafter a procedure is planned. Significant venous sinus stenosis producing high amplitude waveforms resulting in significant clinical symptoms of the raised ICP and all the symptoms gets ameliorated by treating the stenotic lesion.

Venous endovascular procedures are often life saving. By performed thrombolysis and thrombectomy for clots in the cerebral veins, the venous obstruction is opened up and there is resultant decrease in the cerebral congestion.
Sometimes, a stenotic segment of a cerebral vein may need angioplasty (balloon dilatation) and stenting for permanent relief and preventing blindness/death.

Intra-arterial Chemotherapy

Intraarterial chemotherapy is a physiological appealing procedure as the drug gets evenly distributed throughout the tumour capillary vessels and brain parenchyma. Intraarterial treatment of glioblastoma has been attempted since 1950s but the success rate has been quite discouraging. Despite past failures, clinical interest in IA drugs for the treatment of GBM persists. There are several clinical trials with IA GBM treatments with the US national registry. Direct injection of the chemotherapeutic drugs in the tumour feeder vessels makes high concentration of the chemotherapy drugs reaching the tumour bed, could be making them more effective logically.